Field Therapy for Actinic Keratosis: One Nurse Practitioner’s Perspective on Evolving Approaches and Patient-centered Care

J Clin Aesthet Dermatol. 2025;18(7–8 Suppl 1):16–17.

by Amanda Caldwell, FNP-C

Ms. Caldwell is with Dermatology Partners in Warrensburg, Missouri.

Funding: No funding was provided for this article.

Disclosures: The author reports no conflicts of interest relevant to the content of this article.

Background: Actinic keratosis (AK) is a common dermatologic condition that can progress to squamous cell carcinoma if left untreated. Field therapy plays a critical role in managing both visible and subclinical lesions within sun-damaged skin. Objective: The author sought to provide one nurse practitioner’s perspective on the evolving role of field therapy in AK management, emphasizing patient-centered care, real-world challenges for all advanced practice providers (APPs), and personal experience. Methods: This commentary reflects clinical observations, patient interactions, and the author’s own experience undergoing multiple field therapies, including topical 5-fluorouracil, imiquimod, tirbanibulin, and photodynamic therapy. Emphasis is placed on treatment selection, education, and adherence strategies. Results: Field therapy is effective when personalized to the patient’s lifestyle, skin type, and preferences. Empathetic counseling and tailored treatment regimens improve outcomes and satisfaction. Newer therapies such as tirbanibulin and daylight photodynamic therapy offer promising options with improved tolerability. Conclusion: APPs are uniquely positioned to lead in early AK treatment and prevention. Combining clinical expertise with patient education and empathy enhances the impact of field therapy. The author’s dual perspective as a provider and patient offers valuable insight into the real-world application of evidence-based dermatologic care. Keywords: Actinic keratosis, field therapy, advanced practice provider, topical treatment, photodynamic therapy, skin cancer prevention, patient-centered care

Introduction

Actinic keratosis (AK) is one of the most common dermatologic conditions seen in clinical practice, particularly among older adults with cumulative sun exposure. As a dermatology nurse practitioner (NP), I have seen firsthand how AKs can progress to squamous cell carcinoma (SCC), often silently and insidiously. Field therapy has transformed our ability to address widespread sun damage and subclinical lesions—not just the obvious keratoses. This commentary offers clinical insights on field therapy from a frontline NP perspective, including the importance of patient education, tolerability, and adherence.

Why Field Therapy? A Shift from Lesion-Directed Treatment

Historically, AK management centered on lesion-directed therapies—liquid nitrogen cryotherapy being the standard of care. While effective, this approach overlooks the concept of “field cancerization,” a term first introduced by Slaughter et al¹ in 1953 to describe the widespread precancerous changes of photodamaged skin.

In my clinical practice, patients often present with a mixture of visible AKs and background erythema, rough texture, or dyspigmentation—signs of broader ultraviolet (UV) damage. Field therapy provides a mechanism to treat both visible and subclinical lesions, reducing the risk of recurrence and progression to SCC.

Clinical options in field therapy. There are now multiple field therapy options available, and choosing the right one depends on clinical factors, patient preferences, and logistical considerations:

• Topical 5-fluorouracil (5-FU): Often considered the gold standard, 5-FU is effective but can cause significant inflammation. The newer 0.5% and 4% formulations might improve tolerability and adherence.
• Imiquimod: An immune response modifier that can be especially effective for immunocompetent patients but requires motivation to complete longer regimens. Available in 3.75% and 5% formulations which could improve tolerability.
• Tirbanibulin (Klisyri): A newer, five-day topical therapy that disrupts microtubule function, with minimal inflammation and statistically significant efficacy as compared to vehicle.
• Diclofenac 3% in hyaluronan gel base: A longer treatment duration compared to other topicals—best for patients with lower tolerability thresholds.
• Photodynamic therapy (PDT): Excellent for patients with multiple lesions or poor topical adherence. In-office control and cosmetic benefit make it appealing.

Personal Perspective: Provider and Patient

What shapes my approach most is that I’m not just a provider—I’m also a patient. Over the years, I’ve undergone multiple field therapies for my own sun damage, including imiquimod, 5-FU, tirbanibulin, and photodynamic therapy.

Each treatment had its own unique challenges:

• 5-FU left me with bright erythema, scabbing, and visible peeling that lasted for weeks.
• Imiquimod caused delayed but persistent inflammation.
• Tirbanibulin, while brief and convenient, still triggered stinging and crusting.
• PDT involved significant in-office stinging and several days of redness.

Having personally experienced these reactions, I offer more than textbook descriptions—I provide honest, experience-based guidance. I understand the discomfort, the downtime, and the emotional toll. This helps foster trust and allows me to guide my patients with empathy.

Empathy, education, and adherence. One of the greatest challenges we face with field therapy is not the treatment itself—it’s patient adherence. Topical treatments often cause irritation that can be alarming and even distressing. To address this, I employ several strategies:

• Thorough counseling upfront—complete with photos, timelines, and realistic expectations
• Patient check-ins—virtual or in-person, especially during the peak reaction phase
• Customized regimens—such as alternate-day application or supportive skin care
• Because I’ve been through it myself, my reassurances come from a place of authenticity: It gets worse before it gets better—but you are  not alone.

Patient-entered therapy selection. Treatment choice isn’t just about efficacy—it’s about what the patient can and will tolerate. I consider:

• Occupation and lifestyle (eg, those in public-facing roles might prefer PDT over topical agents)
• Support systems at home
• Ability to apply treatments properly and consistently
• Skin type and potential for pigmentary changes
• Insurance coverage and cost

Shared decision-making is essential. One patient of mine, a professional vocalist, declined 5-FU due to appearance concerns. We opted for PDT scheduled between performance seasons—maximizing efficacy and minimizing disruption. These tailored plans create real, sustainable engagement with care.

Emerging Therapies and Combination Approaches

Innovation continues to expand our options:

Daylight PDT offers lower pain with high efficacy and has become a promising choice in Europe.

5-FU + calcipotriol combinations demonstrate synergistic immune activation.

Tirbanibulin, approved in 2020, offers short-duration therapy with mild local reactions—particularly beneficial for patients concerned about downtime.

The role of advanced practice providers (APPs) in skin cancer prevention. As APPs, we’re often on the front lines of early detection. Beyond prescribing treatment, we play key roles in:

• Educating on sun protection and the long-term consequences of UV exposure.
• Performing routine skin exams.
• Advocating for early and proactive therapy.
• Our training in clinical care and patient counseling positions us to bridge the gap between treatment and trust. We can translate medical necessity into patient action.

Conclusion

Field therapy for AK is more than a clinical protocol—it’s a partnership between provider and patient, built on education, empathy, and evidence. As a nurse practitioner and someone who has personally experienced these treatments, I understand both sides of the equation.

The goal is not only to clear lesions but to empower patients to take ownership of their skin health. Whether with 5-FU or tirbanibulin, PDT, or imiquimod, the real success of field therapy lies in the ability to blend science with human connection.

References

1. Slaughter DP, Southwick HW, Smejkal W. Field cancerization in oral stratified squamous epithelium. Cancer. 1953;6(5):963–968.
2. Stockfleth E. The importance of treating the field in actinic keratosis. J Eur Acad Dermatol Venereol. 2017;31(Suppl 2):8–11.
3. Werner RN, Stockfleth E, Connolly SM, et al. Evidence- and consensus-based (S3) guidelines for the treatment of actinic keratosis—International League of Dermatological Societies in cooperation with the European Dermatology Forum. J Eur Acad Dermatol Venereol. 2015;29(11):2069–2079.
4. Berman B, Bienstock L, Kuritzky L, Mayeaux EJ. Evidence-based treatment of actinic keratosis: expert consensus and practical experience. J Drugs Dermatol. 2006;5(5):459–471.
5. Jorizzo JL, Markowitz O, Lebwohl M. Topical treatments for actinic keratoses: 5-fluorouracil formulations. J Clin Aesthet Dermatol. 2016;9(12):E1–E8.
6. Lebwohl M, Swanson N, Anderson LL, et al. Imiquimod 5% cream for the treatment of actinic keratosis: results from two Phase III, randomized, double-blind, vehicle-controlled trials. J Am Acad Dermatol. 2004;50(5):714–721.
7. Samrao A, Perkins B, Butler DC. Ingenol mebutate for actinic keratoses: a review. Dermatol Ther (Heidelb). 2013;3(1):35–46.
8. Martin G, Swanson N, Werth V, et al. A randomized controlled trial of diclofenac sodium 3% topical gel in the treatment of actinic keratoses. Arch Dermatol. 2002;138(11):1492–1498.
9. Szeimies RM, Morton CA, Sidoroff A, Braathen LR. Photodynamic therapy for non-melanoma skin cancer. Acta Derm Venereol. 2005;85(6):483–490.
10. Pariser DM, Lowe NJ, Stewart DM, et al. Photodynamic therapy with aminolevulinic acid topical solution and blue light for multiple actinic keratoses: results of two Phase 3 studies. J Am Acad Dermatol. 2003;48(2):227–232.
11. Rubel DM, Spelman L, Murrell DF, et al. Daylight photodynamic therapy with methyl aminolevulinate cream in Australian patients with actinic keratosis: A randomized controlled trial. Br J Dermatol. 2014;171(4):913–922.
12. Rosen RH, Gupta AK, Tyring SK. Treatment of actinic keratoses with a combination of 5-fluorouracil cream and calcipotriene ointment. J Am Acad Dermatol. 2007;56(2):344–346.
13. Blauvelt A, Kempers S, Lain E, et al. Phase 3 trials of tirbanibulin ointment for actinic keratosis. N Engl J Med. 2021;384(6):512–520.
14. Dunn L, O’Neill JL, Feldman SR. Tirbanibulin ointment: a novel treatment for actinic keratosis. Drugs Today (Barc). 2021;57(1):33–40.